Techniques For Performing Caesarean Section

Techniques for performing caesarean section
Karumpuzha R. Hema* MBBS, MRCOG

Sta Grade in Obstetrics
Richard Johanson* BSc, MA, MD, MRCOG
Senior Lecturer in Obstetrics
North Staordshire Hospital NHS Trust, Stoke on Trent ST4 6QG, UK
In many countries caesarean section has become the mode of delivery in over a quarter of all
births. Safety of the mother and cost are the two main areas of concern. Various studies on the
techniques of performing a caesarean section have focused on reducing the operating time,
bloodloss, woundinfectionandcost. Giventhe fact that caesareansectionis the most commonly
performed operation in obstetrics, it is important that trainers and trainees are familiar with
the basic surgical techniques and that best practice is followed. At the same time surgeons
should take necessary precautions to reduce their risk of exposure to Hepatitis B and HIV.
The skin incision and entry into abdominal cavity is best achieved by the modied Cohen's
incision. The lower segment transverse uterine incision has stood the test of time over a period
of 75 years and remains the best way to enter the uterus. Closure of the uterus in single layer
appears to be acceptable, whenever technically possible. Placental delivery should be by
controlled cord traction after spontaneous expulsion. Closure of the visceral and parietal layers
of the peritoneum no longer seems to be necessary. Obliteration of space in the subcutaneous
layer, either by suture or by suction, seems to reduce wound disruption. These issues are being
considered in the CAESAR randomized controlled trial of surgical techniques currently
underway in England.
Prophylactic antibiotics are mandatory in preventing post-operative morbidity. Many of the
above mentioned steps have been tested in randomized trials. Further studies are needed to
examine a wide range of questions arising fromthis review, e.g. best position of the patient, the
value of exteriorization of the uterus whilst repairing the uterus, and the use of agents to relax
the uterus in dicult deliveries.
Key words: caesarean section; methods; materials; complications; research.
Ever since the wider introduction of caesarean section in the latter part of the 19th
century, the safety of the procedure has improved. Indeed, condence in safety
1
has
increased to the point that, in some countries, nearly a quarter of all deliveries are
now being conducted by the abdominal route.
2
There is currently widespread debate
about the relative merits of abdominal and vaginal delivery
3
and this discussion is dealt
with in depth in Chapter 9.
15216934/01/01001731 $35.00/00 *c
2001 Harcourt Publishers Ltd.
Best Practice & Research Clinical Obstetrics & Gynaecology
Vol. 15, No. 1, pp. 1747, 2001
doi:10.1053/beog.2000.0147, available online at http://www.idealibrary.com on
2
*Address for correspondence: Clinical Governance Support Oce, North Staordshire Hospital NHS Trust,
Ward 58, Maternity Unit, Newcastle Road, Stoke on Trent ST4 6QG, UK.
Improved safety is related to the availability of antibiotics and blood transfusion
1
and
also to advances in anaesthesia, as well as to improvements in technique. The principal
complications are haemorrhage and infection and these, in turn, are related to the
complexity of each case. Prolonged labour, prolonged rupture of membranes and
increased frequency of vaginal examinations all predispose to infection. Previous
caesarean section, placenta praevia and placenta accreta increase the risk of haemor-
rhage. In general, the risks and complications are greater for emergency than for
elective procedures. Generic risks relate to excessive speed and lack of surgical
experience in performing the operation.
While surgical techniques do vary from surgeon to surgeon, good adherence to
basic surgical principles and an awareness of recognized methods of performing
caesarean sections will minimize morbidity. Caesarean section is widely accepted to be
more expensive than vaginal delivery
4,5
, and limiting morbidity will reduce costs. This
chapter deals with techniques for caesarean section, including the relevant aspects of
the basic surgical principles and suturing techniques. In addition, we address
complications of caesarean section. Issues related to anaesthesia and preparation for the
anaesthetic are dealt with separately in Chapter 8.
IDENTIFICATION OF EVIDENCE
For the purposes of this chapter we have carried out the following review of the
literature. The Cochrane Library and the Cochrane Register of Controlled Trials
(RCTs) were searched for relevant RCTs, systematic reviews and meta-analyses. A
search of MEDLINE from 1970 to 1999 was also carried out. The databases were
searched using the relevant MeSH terms: caesarean, repeat caesarean section and
methods.
GENERAL PRINCIPLES
Good practice dictates that the operator should have full knowledge of the patient's
history, especially in relation to any previous surgery. Highlighting the relevant points
of history, and risk factors, on the delivery page in the maternity record will draw
attention to potential diculties. In dierent situations, the exact operative technique
chosen will vary. Factors determining the need to individualize practice include
gestational age, fetal presentation and position, size and number of fetuses, maternal
health and the perceived degree of urgency. Anticipation and proper planning are
important keys to the avoidance of complications. Careful explanation to the mother
of the planned operation prior to surgery and a re sume after the procedure constitute
good clinical practice and are essential risk management. It is clearly very important to
have appropriate assistance and a readiness to call for help when presented with
diculties.
On the basis of surgical studies, it is evident that the choice of correct suture
material may enhance healing. However, there are no published randomized con-
trolled trials on suture material for caesarean section. Nevertheless, the general
principle of choosing a material with sucient tensile strength is accepted. Natural
threads, such as catgut, have largely been replaced by synthetic materials. This is
because they have been shown to cause an inammatory reaction and because they
may harbour infection and also lose their strength capriciously. The non-absorbable
18 K. R. Hema and R. Johanson
synthetic polyamide sutures cause very little reaction and retain their strength reliably.
These sutures decompose in tissue by hydrolysis rather than phagocytosis.
6
The
commonly used monolament sutures are polypropylene (Prolene), polydioxanone
(PDS) and polyglyconate (Maxon). The commonly used multilament sutures are
polyglactin 910 (Vicryl) and polyglycolic acid (Dexon).
Regardless of the actual material chosen, the knot is the weakest link in the suture.
This is the site of maximum foreign body reaction aecting the adjacent layers of tissue.
Although knot security is important, especially when monolament materials are used,
multiple throws beyond the breaking point should be avoided. It has been shown that
knot-holding capacity is maximal with all materials after the addition of a maximum of
two throws to any of the starting knots.
7
Any additional throwwill leave extra amounts
of suture material, leading to increased foreign body reaction. However, when van
Rijssel et al
8
examined suture size and knot volume, they found that the use of thick
gauge suture material addedmore than the additionof extra throws tothe total amount
of foreign body and tissue reaction.
9
They also examined dierent types of knot and
found that, throw-for-throw, square knots were superior to slip knots (see Figure 1) but
that an additional throw to a sliding knot improved its security. Use of the `surgeon's'
knot (Figure 1) is thought to increase the holding power of the rst throwand prevent
slippage and is also considered helpful when there is a high risk of the suture tearing
through a delicate structure. On the other hand, in laboratory studies, the security of
the surgeon's knot was not found to be superior to square knots.
8
Asepsis, minimal and meticulous handling of the tissue, `perfect' haemostasis and re-
approximation of the layers without `strangulation' are essential steps that should be
followed.
10
Dehiscent wounds are almost always found with unbroken sutures and
intact knots, which have cut through the tissue, having been tied too tightly or having
been placed too close to the edge.
7
The best scar results when wound edges, which
retain good blood supply, are opposed without tension or trauma and with a
minimum of foreign material.
Lyon and co-workers, in a reviewthat spanned three decades, showed that morbidity
could be reduced by improving surgical technique. They decreased the needle size used,
switched to polyglycolic sutures, avoided using laparotomy packs (the packs may cause
abrasions, leading to formation of adhesions), used sharp dissection and paid attentionto
the basic rules of surgical practice in minimizing damage to tissues.
11
The problemof latexsensitizationshouldbe consideredinall obstetric patients. Chen
and co-workers, in their interesting study, found that nine of 333 obstetric patients
showed latex-specic immunoglobulin E. When details about atopy, exposure to
condoms, previous deliveries and operations were obtained, it was evident that a
Figure 1. Knots commonly used in surgical practice.
Techniques for performing caesarean section 19
previous caesarean delivery was more frequent in latex-sensitized patients with positive
latex-specic immunoglobulin E (33 versus 8.4%; P 5 0.05). Patients with atopy and
additive risk factors should be treated in a latex-free environment to avoid latex
sensitization.
12
PROTECTING HEALTH PERSONNEL
Precautions are important to avoid risks associated with exposure to, or inoculation of,
body uids e.g. human immunodecient virus. Any contact with sharp objects by the
surgeon and assistants should be kept to a minimum. The use of scissors rather than a
scalpel for extending incisions in the fascia, peritoneum and myometrium may be safer.
After use, sharp instruments need to be transferred in a basin or a tray, to avoid injury.
Retraction of tissues using instruments may be safer than using a hand. Needlestick
injuries can be prevented by mounting the needle onto the holder for transfer after use,
by using forceps to re-position the needle and by mounting the tip and the eye of the
needle together while not in use (Figure 2). If counter-pressure is needed while posi-
tioning a needle, either a tissue forceps or a metal thimble on a nger can be used. The
needleshouldbe cut oandhandedover tothescrubnursebefore tyingthe nal knot.
10
Although double gloving or the use of thicker gloves does not eliminate the risk of
needlestick injuries, it helps to reduce the incidence of such injuries.
13,14
A randomized
prospective study evaluated the use of surgical pass trays to reduce the incidence of
glove perforations during caesarean section. Surgical team members were assigned to
pass the instruments ina normal wayor touse a surgical pass tray. Althoughinthis study
the frequency of glove perforations was not reduced by the use of trays, the authors
found that there were no complete perforations where double glove sets had been
used.
15
Smith and Grant reported glove puncture in 54%of caesarean sections, with 60%
of these occurring at closure.
16
Double gloving reduced the incidence of puncture of the
inner glove by a factor of 6. The use of blunt needles and tissue handling by forceps will
also help to reduce needlestick injuries.
17
Contact with body uids can be minimized by
using a drape with a bag on either side to collect the amniotic uid and the blood. The
use of a clear plastic shield will protect the surgeon and assistants' faces.
Double gloving, use of waterproof gloves and the wearing of spectacles all reduce
the risk of exposure and need to be implemented universally.
POSITION OF THE PATIENT
When pregnant women near term lie in the supine position, the uterus may compress
the inferior vena cava, interfering with the venous return to the heart. This, in turn, is
thought to result in hypotension, hypoperfusion of the placenta and decreased fetal
oxygenation. Hence, it is standard practice that a lateral tilt of 10 to 158 is used while
the caesarean section is performed. Wilkinson and Enkin, in their Cochrane review
18
,
analysed the limited evidence to support this practice from three (poor quality) trials
involving 293 women. When tilt had been used there were fewer low Apgar scores
and better cord pH measurements. However, the authors did not consider the
evidence to be sucient for making denitive recommendations about practice.
18
Interestingly, a recent study by Mattorras and co-workers found no benets in
performing emergency sections with left lateral tilt.
19
CATHETERIZATION
Single catheterization before starting the procedure to avoid injury to bladder is
recommended. The use of an indwelling catheter after caesarean section under epidural
is thought to lessenthe riskof urinary retention andthe need for repeat catheterization.
PREPARATION OF THE SKIN
Infection rates are lowest in cases where shaving is done just prior to the surgery.
Depilatory agents have been shown to be better than razor preparation.
20
The agent
Using thimble Holding needle
Using forceps to
manipulate needle
Figure 2. Technique to avoid needlestick injuries.
used for the skin preparation should be non-toxic, fast acting and easy to apply and
should have broad-spectrum antibacterial activity. Iodophores, such as iodine plus
polyvinyl pyrolidine (povidoneiodine) and tincture of chlorhexidine gluconate (0.5%
in 70% isopropyl alcohol), are usually recommended. However, the use of povidone
iodine should be restricted to intact skin as it contains large molecular fractions which
cannot be excreted completely.
21
Alcohol and hexachlorophane should be used only if
there is hypersensitivity to other usually recommended agents. If 10% alcohol is used
on its own as an antiseptic, diathermy should be used only after full evaporation has
occurred. The use of iodophor-impregnated adhesive lm is protective and allows
rapid skin preparation, provided it is not dislodged at surgery.
22
Pre-operative skin
preparation along with pelvic irrigation with antibiotics was tested in a randomized
study of 100 women.
23
No signicant dierences in the incidences of wound infection
and endometritis were found in a comparison of two agents (povidoneiodine versus
parachlorometaxylenol). However, endometritis occurred signicantly more
frequently in the group that did not receive antibiotic irrigation.
SKIN INCISION
Type of incision
Vertical incision
Traditionally, both transverse and vertical incisions have been used for caesarean
section (Figure 3). Each type has its own advantages. A vertical incision allows a less
Pfannenstiel
incision
Cohen's
incision
Maylard incision
Midline incision
Figure 3. Position of various skin incisions.
vascular rapid entry and good exposure of both the abdomen and pelvis. This incision
may be indicated in cases of urgency, such as massive haemorrhage, when upper
abdominal exploration is required, and at perimortem caesarean section. It may also be
appropriate in patients on systemic anticoagulants or with a coagulopathy and when
those who refuse blood transfusion are operated on.
Pfannenstiel incision
Pfannenstiel introduced the Pfannenstiel incision in 1900 (see references in Stark
et al.
24
). This incision is extensively used because of its excellent cosmetic results, along
with the benets of early ambulation and a low incidence of wound disruption,
dehiscence and hernia. However, the Pfannenstiel incision involves dissection of the
subcutaneous layer and the anterior rectus sheath and, when extended into the
external and oblique muscles, may result in injury to the ilioinguinal and iliohypo-
gastric nerves.
25
In addition, use of this incision limits views of the upper abdomen and
may increase the blood loss and haematoma rate because of the increased dissection.
Mowat and Bonnar reported a wound dehiscence rate of 2.94% (48 of 1635) after a
midline incision, compared to only 0.37% (two of 540) after a Pfannenstiel incision.
26
Similar ndings when comparing transverse and vertical incisions have been reported
by other authors. One group found an eightfold increase in post-operative wound
dehiscence and infection with the vertical incision.
27
On the other hand, when the
emergency use of these incisions was tested in a randomized controlled trial, no
advantages of one over the other were seen in terms of wound disruption and hernia
formation.
21
Ellis in his commentary
21a
stated that the perceived dierence in
morbidity between transverse and vertical incisions may be attributed to the bias in
choosing the incision type, where midline incisions are chosen for emergency
situations such as haemorrhage, sepsis and trauma. The Pfannenstiel incision continues
to be commonly used to perform caesarean sections, primarily for its cosmetic appeal
and also for the perceived dierences in outcome.
28
Joel Cohen's incision
Professor Joel Cohen introduced an incision for abdominal hysterectomy in 1954, and
this incision has since been used widely by obstetricians to perform caesarean
sections.
29
The incision is a straight transverse incision, positioned slightly higher than
the Pfannenstiel (Figure 3). The subcutaneous tissue is not sharply divided. The
anterior rectus sheath is incised in the midline for 3 cm, but the muscles are not
separated from the sheath. The peritoneum is bluntly opened in a transverse direction
and, with the assistant's help, the opening is widened by traction in a transverse
direction. Cohen and Pfannenstiel incisions were compared in a retrospective study in
245 women who underwent caesarean section.
29
The length of the operation was less
by 1.6 minutes, and post-operative morbidity was also less in the Cohen's incision
group (7.4 versus 18.6%; P 5 0.05).
`Modied' Joel Cohen's incision
Wallin and Fall
30
carried out an RCT of standard and `modied' Cohen's methods of
caesarean section with 36 women in each group. In the modied Cohen's method,
they placed the incision 3 cm above the pubic symphysis and bluntly opened the
peritoneum (Figure 3). In addition, they did not close the parietal and visceral layers of
the peritoneum. They found a reduced intraoperative blood loss (250 versus 400 ml:
P 0.026) and a reduced operating time (20 versus 26 minutes; P 5 0.001) in the
modied Cohen's group.
The Cohen's incision has been examined in a number of RCTs where modications,
such as single-layer closure of the uterus and non-closure of parietal and visceral layers
of peritoneum, have also been evaluated
31,32
(Table 1). Darj and Nordstrom com-
pared Joel Cohen's incision (n 25) with Pfannenstiel's incision (n 25) and reported
less operating time (12.5 versus 26 minutes; P 5 0.001), less blood loss (448 versus
608 ml; P 0.017) and less analgesic requirement (P 0.004) with the Cohen's
incision.
31
The study did not reveal any negative aspects of using the new technique.
This technique is well described, with gures, in the paper published by Holmgren,
Sjoholm and Michael Stark.
32
This package of renements in techniques was intro-
duced by Michael Stark and is known, after a hospital in Jerusalem, as the `Misgav
Ladach method'.
Maylard incision
Another transverse approach has been described: the Maylard incision (Figure 4),
which involves cutting the rectus muscles transversely and ligating the inferior
epigastric artery to provide good access to the pelvis. This incision was originally
described for use in radical pelvic surgery. It is comparable to vertical incisions in
terms of complications and outcome.
33,34
Ayers and Morley, in their randomized trial
comparing Pfannenstiel and Maylard incisions for caesarean sections, did not nd any
dierence in morbidity.
35
They suggested that the Maylard incision is a safe option
which should be strongly considered when risk factors are present, such as macro-
somia or twins needing maximal exposure for a non-traumatic delivery. Although
there was no increase in blood loss and post-operative morbidity with the Maylard
incision, it is clear that, because more dissection is required, post-operative discomfort
is likely to be greater.
10
Inferior epigastric
artery and vein
Figure 4. Maynard incision explained. Inferior epigastric vessels ligated and recti muscles cut.
Length of incision
Whatever type is chosen, the length of the incision should be adequate. A dicult
caesarean section should not be a substitute for a dicult vaginal delivery. The incision
should be approximately the same length as an Àllis' clamp, laid on the skin (15 cm).
Finan and co-workers showed in their prospective study that the time (uterine
incisiondelivery) was shorter in the group that passed the Àllis test', compared to
the group that failed the test (mean 58.4 versus 95.7 seconds, P 0.002).
36
Previous scars
As already indicated, wound healing is aected if the edges are not approximated
properly. This becomes an important point to remember whenever previous scars are
encountered. Excision of the previous scar will improve wound healing and gives
better cosmetic results. Bowen and Charnock found, in a series of 25 women
undergoing repeat caesarean section, that the use of a double-bladed scalpel yielded
better healing and aesthetically more pleasing scars than the conventional scalpel. This
is because it uniformly excised the scar tissue and avoided the need for two incisions.
An adjusting screw allows the necessary width to be excised
37
(Figure 5).
Method of incision
The time-honoured practice of using two scalpels at caesarean section (one for the skin
and sheath and a dierent one for internal divisions) has been studied. No dierence in
wound infection was found with the use of either one or two scalpels.
38
Another study
revealed that the rst scalpel usually remained sterile.
39
Whichever scalpel is used, the
incision should be made using one stroke rather than with multiple strokes, which
may lead to infection and poor healing.
40
Nygaard and Squatrito
21
, in their review of methods of abdominal incisions, have
discussed the merits identied in various studies of a scalpel compared to ultrasound
knife, laser or diathermy. Although animal studies have shown that the scalpel is
Figure 5. Double-bladed scalpel.
associated with less tissue damage, ndings from controlled studies in humans are
mixed. The authors comment that, with some exceptions, the bulk of the literature on
humans suggests little advantage or disadvantage toincisions madewithscalpel, cautery,
or laser.
21
Uterine incision
Lower segment transverse incision (Kerr) (Figure 6)
Ever since its introduction in 1926 by Munro Kerr
41
, the lower segment incision has
been the most commonly performed uterine incision. A Doyen's retractor is used for
good exposure of the lower segment. The loose fold of peritoneum, where the
bladder is attached, should be identied. Before an incision is made, rotation of the
uterus should be noted (it is usually dextro-rotated) and, if possible, corrected, so that
the incision will not be asymmetrical, risking extension on the opposite side. The loose
fold of peritoneum should be incised and the bladder pushed down gently with care,
mainly in the centre in order to avoid disturbing the vascular plexus.
22
In cases of
obstructed labour, with formation of Bandl's ring, this fold of peritoneum is located
higher and the peritoneum should be opened higher up, with particular care to avoid
bladder injury.
The uterine incision should be made in the centre, for a length of 23 cm, until the
membranes are exposed. In order to avoid injury to the fetus, the deeper bres of the
myometrium should be opened with the blunt end of the scalpel or with ngers.
Extension of the incision should be achieved by ngers along the path of least
resistance. It must be remembered that the force used on the left side should be less
than that on the right side to avoid haemorrhage from the left angle. This risk can
usually be minimized by correcting the dextro-rotation. If sharp dissection is required,
the use of thick bandage scissors is recommended for cutting the thick lower segment
Lower segment
incision
'Classical'
incision
De Lee's
incision
Figure 6. Position of various uterine incisions.
in a concave manner to avoid injuring the fetus and the major uterine blood vessels.
22
However, Rodriguez and co-workers, in their RCT of blunt versus sharp extension of
the incision, did not nd any dierence in ease of delivery, blood loss, unintended
extension or post-operative endometritis.
42
When dicult circumstances are
encountered, requiring an extension of the transverse incision, a `J'-shaped extension
into the upper segment, on the most accessible side, is better than an inverted `T'
incision (which will form a weaker scar due to poor healing). However, both of these
incisions have been shown to be frequently associated with intraoperative com-
plications and prolonged hospital stays.
43
Extension of the uterine decision using an absorbable stapling device, called Auto
Suture Poly CS, has been described. After a small incision, the stapling device is
introduced between the membranes and the uterine wall. The stapler is then red to
produce two columns of absorbable staples. Thereafter, a hysterotomy is performed
between the rows of the staples. However, in an RCT between the conventional type
and the stapling type of caesarean section, the operating time was prolonged and the
other measures of outcome were the same. Hence, its routine use is not recom-
mended.
44
A Cochrane review analysed four trials involving 526 women where the
stapling device was used to extend the incision. There was no dierence in the total
operating time compared with the other techniques used to extend the incision, but
the stapler increased the time needed to deliver the baby (weighted mean dierence
0.85 minutes, 95% Cl 0.48 to 1.23). Blood loss was lower with the stapling device. The
reviewers conclude that there is not enough evidence to justify the routine use of the
stapling device to extend the uterine incision. Indeed, there is a possibility that this
device could cause harm by prolonging the time to deliver the baby.
45
Lower segment vertical incision (De Lee and Cornell) (Figure 6)
The lower uterine vertical incision, introduced by De Lee and Cornell
46
, has the
advantage of sparing the uterine vessels but it needs careful dissection to reect the
bladder, which may nevertheless become involved in an extension. The incidence of
scar dehiscence is equivalent to that expected with the transverse incision and it may
be regarded as an alternative to the upper uterine vertical incision.
46a
Shipp and co-
workers have also shown that women with a prior lower vertical incision are not at an
increased risk of uterine rupture compared to those who have had a lower transverse
incision.
47
No statistical dierences in terms of perinatal and maternal morbidity were
noted when singleton breech fetuses were delivered via lower transverse (n 221) or
lower vertical incisions (n 195).
48
The lower segment transverse incision has also
been compared with the vertical incision in triplet pregnancies. In a case-controlled
study, no signicant dierences were observed in perinatal mortality or operative
complications.
49
Because of the risks of bladder extension, it remains advisable to do a lower
segment transverse incision whenever the lower segment is well formed. Where this
is not the case, then a low vertical incision is acceptable.
Classical incision (Figure 6)
In recent years, the rate of `classical' incision has gone up, due particularly to increased
preterm deliveries, especially those performed before 26 weeks of gestation or after
rupture of membranes. Bethune and Permezel, in their retrospective study
undertaken over a 9 year period in Melbourne, noted that 1% of all their caesarean
sections were `classical'. The frequency correlated inversely with the gestational age:
20% at 24 weeks, 5% at 30 weeks, and less than 1% from 34 weeks onwards.
50
The `classical' upper segment vertical incision is thought to be associated with
excessive blood loss, infection, poor healing and an increased risk of rupture in
subsequent pregnancies. However, Blanco and Gibbs found comparable early
morbidity and wound infection rates between two groups of women who had
lower segment transverse and classical incisions.
51
They attributed this to improved
surgical techniques. `Classical' sections are indicated when the lower segment is
inaccessible due to dense adhesions or large broids. This route may also be necessary
with preterm breech presentations or with a transverse lie and prolonged rupture of
membranes (particularly those that are `dorsoinferior'). Placenta praevia in general is
no longer regarded as an indication for a classical section
22
, but this incision should be
undertaken at perimortem caesarean (Table 1).
Delivery of the fetus
In an observational study of 105 deliveries, inductiondelivery intervals of more than
8 minutes under general anaesthetic and incisiondelivery intervals of more than
3 minutes under both general or spinal anaesthetic were associated with increased
numbers of low Apgar scores and neonatal acidosis.
52
The same group found that with
longer uterine incisiondelivery intervals, umbilical arterial (UA) noradrenaline
concentrations increased signicantly, resulting in lower UA pH values.
53
However,
Vatashsky and co-workers (n 568) and Anderson and co-workers (n 204)
concluded after their studies on the inuence of incisiondelivery interval that it
did not signicantly aect the outcome.
Both a high head and a deeply engaged head could pose problems with delivery.
Ideally, the fetal head should always be delivered in an occipito-anterior position.
Management of the dicult situations that may arise in this area are discussed later in
this chapter. When faced with diculties, a general principle is that uterine relaxation
may help. Glyceryl trinitrite has been used intravenously in a randomized double-blind
trial at elective caesarean section.
54
Although routine administration of glyceryl
trinitrite in elective cases did not have signicant benets, there were no signicant
maternal or fetal side-eects to the drug. In the light of this nding, it may be worth
trying this in dicult deliveries.
Injury to the fetus during caesarean section is not uncommon and is often under-
reported. These injuries are likely to occur at the time of uterine incision or at
extraction of the fetus. The legal literature contains several cases involving scalp wounds
resulting from incisions during caesarean section. Such injuries cannot be considered as
èxpected' complication.
55
Durham and co-workers even reported an iatrogenic brain
injury during emergency caesarean section. There have also been reports of long bone
Table 1. Classical caesarean section: possible indications.
Preterm delivery with poorly formed lower segment
Premature rupture of membranes, poor lower segment and transverse lie
Transverse lie with back inferior
Large cervical broid
Severe adhesions in lower segment reducing accessibility
Postmortem caesarean section
Placenta praevia with large vessels in lower segment
fractures and of extensor tendon laceration in pretermneonates.
55,56
The use of a newly
devised, blunt-edged, notched scalpel has been shown to be easy and safe for making
uterine incisions (Figure 7).
57
There were no major complications or fetal injuries when
the authors used this tool in 41 women at caesarean delivery.
Delivery of the placenta
Traditionally the placenta is removed manually at the time of caesarean section. The
method used should not be any dierent from the controlled cord traction used at
vaginal delivery. Manual shearing of the placenta does not allow time for retraction of
the myometrial bres, and hence leads to unaltered perfusion and increased blood loss.
Four randomized trials comparing manual extraction and controlled cord traction for
expulsion of the placenta have been undertaken
5861
(Table 2).
Wilkinson and Enkin, in their systematic Cochrane review, conclude that manual
removal of placenta at section may do more harm than good by increasing maternal
blood loss and increasing the riskof infection.
62
In a recent study, Lasley and co-workers
found that post-operative infections occurred in 25 of 168 (15%) women in the
spontaneous group compared with 44 of 165 (27%) in the manually delivered group
(relative risk 0.6%, 95% condence interval 0.4 to 0.9, P 0.01). The incidence of
infection in the sub-group of women with ruptured membranes signicantly increased
in the manual extraction group (20 versus 38%, relative risk 0.5. 95% Cl 0.3 to 0.9,
P 0.02).
61
Yancey and co-workers isolated non-staphylococcal bacteria from surgeons' gloves
soon after fetal extraction in 11 out of 14 labouring women, as compared to one of 11
non-labouring women.
63
Based on this nding, Atkinson and co-workers conducted a
randomized study in a large number of patients (n 643) who were divided into four
groups. In this study the eects of a glove change for surgeon and assistant, just after
Figure 7. Blunt-edged notched scalpel.
delivery of the fetus, along with a spontaneous delivery of the placenta, were compared
to a policy of manual removal and no glove change. Although they found that changing
gloves was not associated with a reduced incidence of post-operative endometritis, they
conrmed that manual removal was associated with a greater risk of post-caesarean
endometritis
64
(Table 2). In a smaller study which looked at intraoperative `glove
change' no signicant dierences were noted in measures of post-operative morbidity.
65
The practice of exploring the uterus with a gauze sponge after delivering the
placenta (to check for retained placental cotyledons or membranes) has not been
tested properly. This practice could theoretically increase the chances of bacterial
contamination and hence post-operative endometritis. However, as the uterus is well
contracted at this stage, the chances of bacterial inoculation deep into the decidua and
the myometrium are small.
61
At elective caesarean section, some operators choose to
dilate the cervix with ngers or dilators after delivery of the placenta. This practice has
not been tested in randomized trials and could, theoretically, introduce infection and
cause damage to the cervix.
Exteriorization of the uterus
Exteriorization and traction on the uterus has been shown to reduce blood loss and
facilitate suturing.
66
However, exteriorization may cause nausea and vomiting and
some women do complain of pain. Using Doppler monitoring, a signicantly higher
incidence of venous air embolism was reported by Handler and Bromage.
67
The theory
of this can be explained: traction enlarges the uterine sinuses and raises the incision to
a level higher than that of the heart, and this increases the hydrostatic gradient,
thereby promoting venous air embolism.
68
Prospective trials of exteriorization of the
uterus to repair the uterine wound have been evaluated by Enkin and Wilkinson, who
found that, because of unsatisfactory randomizations and unspecied exclusions, there
Table 2. Placental delivery.
Subject
Number of
patients Country Author Year Result
Spontaneous expulsion/
manual extraction
31/31 USA McCurdy &
co-workers
59
1992 Less blood loss;
lower incidence of post-
operative endometritis
Spontaneous versus manual
placental removal combined
with exteriorization/in-situ
repair (four groups)
100 USA Magann &
co-workers
60
1993 Less blood loss and post-
operative morbidity
with spontaneous
expulsion and in-situ
repair
Spontaneous versus manual
extraction combined with
glove change/no glove
change after delivery of the
fetus (four groups)
760 USA Atkinson &
co-workers
64
1996 No signicant change in
morbidity with or
without glove change;
lower incidence of
endometritis with
spontaneous placental
delivery
Spontaneous expulsion
versus manual extraction
168/165 USA Lasley &
co-workers
61
1997 Lower incidence of post-
operative infections with
spontaneous expulsion
were insucient data to permit denitive conclusions about exteriorization.
69
However, a recent RCT (n 194), which avoided the major drawbacks of previous
studies, indicated that maternal morbidity was not increased with exteriorization
70
and in another recent RCT (involving 316 women) the authors found no signicant
dierences in post-operative wound sepsis, pyrexia, blood transfusion or length of
hospital stay. They concluded that, with eective anaesthesia, exteriorization is not
associated with signicant problems and is associated with less blood loss ( p 5 0.05).
71
Closure
Suturing of the uterus
Traditionally the uterine wound is closed, as was recommended by Kerr in 1926
41
, in
two layers. The traditional two-layer suturing technique was borrowed directly from
the initial vertical incision closure.
22
Until fairly recently, recommendations varied
only in terms of the method of actual suturing: locking, continuous or interrupted. In
1976 Pritchard and MacDonald
72
rst noted that a satisfactory approximation of the
edges can be obtained by a single-layer closure. Theoretically, single-layer closure
should cause less tissue damage, include less foreign material and take less operative
time. Hauth and co-workers
72a
randomized 906 women and compared the two
methods. Their conclusion was that a one-layered locking suture closure required less
operative time, (43.8 versus 47.5 minutes (P 0.0003)). In no outcome assessment,
such as haemostasis or endometritis, was the two-layer closure superior to the single-
layer closure.
72
Insertionof interruptedhaemostatic sutures was requiredfor 16 women
in each group. The authors recommended a single-layer closure, when anatomically
feasible. A single-layer closure can be achieved using a Polyglactin No. 1 suture with a
locking or non-locking method. Animal studies, histological and hysterographic
studies, have demonstrated that a single-layer closure provides the best anatomical
result and the strongest scar.
73
Concerns about the integrity of the scar during a subsequent trial of labour after
single-layer closure have been examined in a retrospective cohort study of 292 women
(149 after a one-layer closure and 143 after a two-layer closure).
74
Tucker and co-
workers found that asymptomatic ruptures were not higher in the single-layer group.
Eight women had scar dehiscence in the single-layer closure group, as compared to ve
in the two-layered closure group.
75
Chapman and co-workers studied the outcome of
subsequent delivery in a group of 164 women who had previously been randomized to
single-layer closure (n 83) or double-layer closure (n 81). Of these 164 women, 145
experienceda trial of labour. Therewere nodierences betweenthe twogroups during
a subsequent trial of labour, in terms of maternal or fetal outcome measures.
76
The classical incision needs to be closed in three layers because of its thickness and
vascularity. Traditionally about six àll layer' interrupted sutures are placed but not
tied. Thereafter a `herring-bone' suture is used for the deep and middle layers. The
supercial myometrium and serosa are then juxtaposed by a non-locking continuous
suture, followed by ligation of the àll layer' interrupted sutures (see Figure 8).
Peritoneal closure
The traditional arguments for peritoneal closure have included, rst, restoring the
anatomy and approximation of tissues for healing, and second, the re-establishment of
a peritoneal barrier to reduce the risk of wound herniation or dehiscence. In addition,
peritoneal closure was thought to minimize the formation of adhesions.
77
Buckman and co-workers have shown that deperitonealized surfaces heal without
permanent adhesions. The closure of peritoneum at the time of caesarean section has
been examined in four RCTs. The Cochrane review by Wilkinson and Enkin concluded
that there seems to be no signicant dierence in short-term morbidity with non-
closure of the peritoneum at caesarean section and that non-closure of the peritoneum
saved operating time (weighted mean dierence of 612 minutes, 95% Cl 8.00 to
4.27). There was a consistent, although non-signicant, trend for improved
immediate post-operative outcome.
78,79
The results of the trials that have now been
published are given in Table 3. It is evident that non-closure of the parietal and visceral
layers of peritoneum is likely to be cost eective, time saving and, above all, associated
with less post-operative morbidity, as well as requiring less analgesia.
7883
Closure of fascia
The rectus sheath is commonly closed using a synthetic suture. Wound healing is best
if the stitches are inserted 10 mm from the edge and 10 mm apart. This is because
collagenolysis occurs over an area of 10 mm from the wound edge. Any wound
closures constructed within this zone will therefore be weaker.
10
Closure of Camper's fascia
Wound infection can cause disruption of the wound, requiring opening and drainage
and a protracted healing time. The formation of seromas and haematomas due to the
dead space in the subcutaneous layer can lead to infection. Del Valle and co-workers,
in their RCT conducted on 438 women, used 3-0 pain catgut continuous suture to
approximate the Camper's fascia. They found that wound disruption was less in this
group, compared to the non-closure group, (2.7 versus 7.4%; P 0.03).
84
However, no
analysis was made in terms of the depth of the subcutaneous tissue.
84
In another
a
b
Figure 8. Closure of classical section. (a) Àll layer' suture; (b) `Herring-bone' suture.
prospective trial, 245 women with a subcutaneous space of 2 cm or more were
randomized to closure of subcutaneous space with a 3-0 polyglycolic acid suture or to
non-closure. The incidence of infections in the two study groups, from all causes, was
14.5% in the closure group compared to 26.6% in the non-closure group (RR 0.5, 95%
Cl 0.30.9).
71,85
An alternative to suturing Camper's fascia is to leave a drain above
the sheath with continuous suction. An RCT was conducted by Saunders and Barclay
in 200 women undergoing lower segment caesarean section.
86
They placed a Redivac
drain behind the sheath and closed the sheath with Polyglactin sutures. They did not
nd any signicant advantage to the routine use of the drain in non-obese patients.
86
The use of closed suction drainage in òbese' women (42 cm subcutaneous tissue) has
been shown to reduce wound complications.
87
Table 3. Peritoneal closure.
Subject
Number of
RCT between non-
closure versus closure
of parietal layer
127/121 USA Pietrantoni &
co-workers
122
1991 Shorter operating time;
no dierence in
morbidity
RCT of non-closure
versus closure of
visceral and parietal
layers
117 USA Hull and
Varner
123
1991 Reduced need for post-
operative analgesia;
quicker return of bowel
function
RCT of non-closure
versus closure of
visceral and parietal
layer
300 Switzerland Luzuy et al
124
1994 Shorter operating time
(P 5 0.005); shorter
hospitalization
RCT of both layer
closure versus non-
closure 1 year post-op
follow-up
192/179 UAE Grundsell &
co-workers
81
1991
1994
Less post-operative
febrile morbidity; less
wound infection
(P 5 0.001); shorter
operating time
(P 5 0.01)
RCT non-closure/
both layers closure
96/94 Malaysia Ho & co-
workers
125
1997 No dierence in post-
operative morbidity;
shorter operating time
RCT double-blind
study (post-operative
pain assessment)
21/19 Denmark Hjberg &
co-workers
82,83
1996/
1998
Overall, no dierence in
post-operative pain; use
of analgesic
requirements reduced
in non-closure group
from 3rd day
RCT non-closure/
closure of visceral
peritoneum
262/287 Austria Nagele &
co-workers
126
1996 Lower febrile and
infectious morbidity;
shorter operating time;
use of analgesic
requirements reduced
in non-closure group
RCT closure/non
closure of the visceral
and parietal layers
137/143 Canada Irion &
co-workers
127
1996 Lower post-operative
morbidity and pain;
shorter operating time
Closure of skin
Skin edges of the incision can be approximated either by intracutaneous sutures,
staples or clips, or by subcuticular sutures. The choice is usually based on the surgeon's
preference, speed and cosmetic advantage. The subcuticular suture has particular
advantages based on its cosmetic appeal. In studies which compared sutures and staples
at the time of laparotomy (with a vertical incision), subcutaneous polydioxanone (PDS)
was found to give the best results.
88
A non-randomized Danish study compared three
methods of skin closure. The best cosmetic outcome, from both the mother's and
surgeon's perspective, was obtained with subcuticular sutures.
89
The rst randomized trial, looking at Pfannenstiel incision closure at caesarean
section was conducted by Frishman and co-workers on 50 women; it compared staples
with subcuticular polyglycolic acid sutures. The patients who had subcuticular suturing
felt less pain at discharge and at the post-operative visit (P 5 0.01 and P 0.002). The
subcuticular repair was cosmetically more attractive to both the patients and the
surgeons at the post-operative visit (P 0.04, P 0.01).
90
A prolene subcuticular
suture has the advantage over Dexon that it can be removed in the early post-
operative period
22
, but this suture has not been tested in randomized trials.
The use of cyanoacrylate (a skin `glue') to close the skin at caesarean section has
been evaluated in a series of 44 patients. In this case-controlled study, using nylon and
silk, the authors found cyanoacrylate to be safe and ecient, reducing both the time
and cost of skin closure.
91
Further evaluation is required.
Delayed closure has been proposed where there are signicant concerns about ooze
into the wound. Brigg and colleagues studied the eects of primary versus delayed
closure in cases of HELLP (haemolysis, elevated liver enzymes, low platelets)
syndrome, and at the same time they compared Pfannenstiel and midline incisions.
In this study, they found that the wound complication rate was not inuenced by skin
incision or timing of skin closure.
92
THE MISGAVLADACH METHOD OF CAESAREAN SECTION
As indicated above, a number of dierent features discussed in this section contribute
to the MisgavLadach method of caesarean section. The whole procedure can be
summarized as follows.
The principal features followed include the Joel Cohen method of opening the
abdomen, suturing the uterus in one layer and non-closure of visceral and parietal
layers of peritoneum. Holmgren and co-workers carried out a retrospective compara-
tive study between this method and the conventional method (Pfannensteil incision,
with two-layered uterine closure of both the peritoneal layers).
32
They concluded that
the incidence of febrile morbidity, adhesions and analgesic requirements was lower in
the MisgavLadach method. The method is well described and the steps are illustrated
in gures by the authors in their article.
32
Table 4 summarizes the methodology and results of various trials related to this
technique of caesarean section. The details of these have already been separately
discussed in the text. The advantages of this approach include a quicker post-operative
recovery, lower febrile morbidity and antibiotic requirement, early return of bowel
movements and fewer adhesions.
FUTURE RESEARCH INTO TECHNIQUE
A randomized factorial trial is under way in the United Kingdom, organized by the
National Perinatal Epidemiology Unit, in Oxford, called the CAESARean trial. This
is based on an initial survey undertaken among obstetricians which determined
(a) current practice with respect to the techniques used at caesarean section, and
(b) what aspects of the operation clinicians would like to see evaluated in a randomized
controlled trial. The trial will assess the following three pairs of alternative surgical
techniques (1) single versus double-layer closure of the uterus, (2) closure versus non-
closure of the pelvic peritoneum, and (3) restricted versus liberal use of sub-sheath drain
(The CAESAR study Protocol, National Perinatal Epidemiology Unit, Oxford).
ANTIBIOTICS IN CAESAREAN SECTION
Prophylactic antibiotics for caesarean section have been shown to reduce the incidence
of maternal post-operative infectious morbidity. In a systematic Cochrane review on
this subject, 51 trials were analysed.
93
The odds ratio (95% Cl) for their eect on
Table 4. Study of combinations of methods.
Subject
Number of
RCT of single-layer uterine
closure and non-closure of
peritoneum versus double-layer
uterine closure and visceral and
parietal layer closure
100/100 Israel Ohel &
co-workers
80
1996 Less operative time
(32 + 11 versus
44 + 16); less post-
operative sedation
RCT of two surgical techniques.
Joel Cohen's entry, single, non-
locking uterine closure, non-
closure of both peritoneal layers
versus Pfannenstiel's opening,
single uterine layer and closure
of both peritoneal layers
149/153 Italy Franchi &
co-workers
74
1998 Less operating time;
less wound infection
RCT of MisgavLadach method.
Joel Cohen's entry, single
uterine layer, locking suture,
non-closure of peritoneum
versus Pfannenstiel's incision,
double-layer uterine closure
and closure of both parietal and
visceral layers
25/25 Sweden Darj &
Nordstrom
31
reduced blood loss
(P 0.017); less
analgesic
requirement
RCT MisgavLadach method.
Cohen's entry, single locking
uterine closure versus non-
closure of peritoneum
interrupted skin closure; lower
midline incision double uterine
layer closure with closure of
both parietal and visceral layers
339 Tanzania Bjjorklund &
co-workers
128
less blood loss
serious infectious morbidity/death is 0.25 (0.110.56). The particular antibiotic that is
used does not appear to be very important. Both ampicillin and rst-generation
cephalosporins have a similar ecacy, with an odds ratio (OR) of 1.27 (95% Cl: 0.84
1.93). In comparing ampicillin with a second- or third-generation cephalosporin, the
odds ratio was 0.83 (95% Cl: 0.541.26) and in comparing a rst-generation
cephalosporin with a second- or third-generation agent the odds ratio was 1.21
(95% Cl 0.971.51). A multiple-dose regimen for prophylaxis appears to oer no added
benet over a single-dose regimen; OR 0.92 (95% Cl 0.701.23). Systemic and lavage
routes of administration appear to have no dierence in eect; OR 1.19 (95% Cl 0.81
1.73). In addition, the reviewers conclude that there is a need for an appropriately
designed randomized trial to test the timing of administration of antibiotics
immediately after the cord is clamped versus pre-operatively.
93
Similar studies will not necessarily have the power to assess these questions. For
example, a study by Rizk and co-workers concluded that administration of
prophylactic antibiotics at elective sections (61 placebo versus 59 sections) was not
associated with any reduction in post-operative morbidity.
94
Similarly, Rouzi and
colleagues, in their placebo-controlled RCT (211 elective sections and 230 emergency
deliveries), found that routine use of a single dose of cefazolin is eective in emergency
sections but not in elective deliveries.
95
Studies such as these contribute to the debate
about the need for universal prophylaxis. It may not be necessary in units that can
prove that they have low infection rates. Interestingly, if follow-up extends to the
community, even units with high rates of prophylaxis continue to have late infec-
tions.
96
Further research should have longer term outcomes and not just hospital-
based infection rates.
COMPLICATIONS DURING CAESAREAN SECTION
The rising caesarean section rate in the past two decades indirectly vouches for its
safety. Nevertheless, it is associated with increased morbidity for the mother, and the
procedure can result in serious complications. The need for blood transfusion is
greater when trainees perform caesarean sections without supervision.
97
Yet this is an
operation commonly performed by trainees and residents. A regular review of the
methods used, along with good supervision and, where available, periodic training in a
`skills laboratory', will all help to reduce complications.
The following were identied as risk factors for complications at caesarean section:
excessive speed, lack of experience, gestational age 532 weeks, ruptured membranes
and low station of the presenting part. The Condential Enquiries into Maternal
Mortality have consistently referred to the need for senior obstetricians to be involved
early in the event of complications.
98
Ideally, all high-risk cases should be performed
during the daytime, when the availability of expertise is maximum. Anticipation is the
key to avoidance of complications.
99
Complications are increased in emergency
procedures. A comparative series from Cape Town suggested that the relative risk for
mortality, after excluding medical disorders and major antenatal complications, of
intrapartum emergency versus elective sections, was 1.7:1.0.
100
There can be diculties encountered at various stages while performing an
abdominal delivery. These include: dicult entry into the peritoneal cavity due to
dense adhesions, diculties associated with obstructed labour, and diculties due to
limited exposure and space in the lower segment. The last problem occurs especially in
preterm sections with ruptured membranes and with abnormal presentations of the
fetus. Each case needs to be managed on an individual basis.
Dicult deliveries at caesarean section
A high head at elective section may give rise to diculty in delivering the fetus. The
rule of thumb is to deliver the fetus in a exed position, very similar to the fetal
attitude in utero. In such situations the head can be delivered by applying a pair of
Wrigley's forceps, or one forceps blade can be used as a vectis to gently lever out the
head (this blade occupies less space than the hand). The ventouse can also be used to
extract the fetus at caesarean section.
101
However, in one series this was shown to
increase the incisiondelivery interval and hence caution is necessary.
102
In cases of
direct occipito posterior position, the head should be exed before delivery and a pair
of forceps may need to be used.
With face or brow presentations the same principle needs to be applied: èx and
deliver'. Breech delivery should be conducted in the same way as vaginal breech
deliveries, using slow and steady traction, avoiding unnecessary speed. Either both feet
or one foot (if only one is accessible) need to be grasped and gentle traction will enable
a smooth assisted delivery. Delivery of the shoulders needs to be conducted in the
same way as in a vaginal delivery, by gentle rotation. Delivery of the after-coming head
can be dicult, especially in emergency caesareans or after rupture of membranes.
The assistant needs to maintain pressure on the fundus of the uterus and Mauriceau-
Smellie-Veit's technique or forceps delivery may be helpful.
With a transverse lie, an external cephalic or podalic version should be tried before
the uterus is incised! If unsuccessful, an internal podalic version will need to be
undertaken. It is not very uncommon to nd a hand within easier reach than the foot.
It is therefore important to identify the limb carefully before beginning an extraction.
If a hand is grasped, it needs to be pushed back gently and the delivery should be
completed as a breech extraction.
In placenta praevia, when the placenta is encountered anteriorly at the level of
incision, it should simply be pushed aside to expose the membranes. The placenta itself
needs to be incised only when the former steps are not possible.
Where a caesarean section is performed in the second stage of labour or after failed
trial of instrumental delivery, it may be helpful if an assistant pushes the head from
below or, alternatively, the fetus can be delivered by breech extraction.
103
Preterm caesarean section
Physiological studies suggest that cord clamping delayed by 30 seconds in preterm
infants, born between 26 and 33 weeks, increases the placental transfer of fetal blood
by 1520 ml/kg. However, when the eects of immediate versus delayed clamping
(by 30 seconds) were studied, no signicant change in the haematocrit was noted. The
authors recommend that future studies be done to examine the benets of delaying
clamping for more than 30 seconds.
104
Preterm infants (2432 weeks of gestation) in theory benet from delivery èn caul'
(with an intact sac at the time of delivery) but authors from Leeds observed a relatively
high rate of fetal blood loss.
105
Maternal blood loss is reported to be more with
preterm caesarean sections.
106
In a case-controlled study, caesarean section before 28
weeks of gestation was shown to be associated with increased maternal morbidity.
107
Haemorrhage in caesarean section
The average blood loss at caesarean section is about 0.71.01 litres.
59
However, blood
loss is usually underestimated, particularly when this has been large. This has been
shown in a prospective observational study, using the alkaline haematin method,
carried out on 40 women at elective caesarean section.
108
When the measured blood
loss was less than 500 ml it was estimated with reasonable accuracy, but amounts were
signicantly underestimated when the measured loss exceeded 600 ml.
108
Among the
risk factors known to be associated with increased blood loss are prolonged labour,
second stage caesarean section, placenta praevia, chorioamnionitis, antepartum
haemorrhage, previous postpartum haemorrhage, preterm caesarean section, classical
incision, general anaesthesia and obesity.
Precautions and prevention
A caesarean scar increases the incidence of placenta praevia in subsequent
pregnancies.
99
At caesarean section for placenta praevia, it is recommended
98
that a
senior obstetrician and anaesthetist be present in theatre. Patients with placenta
praevia need to be informed of the possible complications and the possible need for
further surgical procedures, including hysterectomy. There should be cross-matched
blood available in theatre before the operation is started.
Second-stage caesarean sections need to be performed with caution. Delivering the
fetus in a exed position using steady traction is important in terms of reducing the
blood loss. When the uterine vessels become involved, due to an unintended lateral
extension of the incision, the artery needs to be ligated separately. Caution needs to
be exercised when suturing the angle, especially in the presence of excessive bleeding.
The bleeding edge may be inverted while inserting a haemostatic suture, hiding the
bleeding point from view.
Aetiology and steps of treatment
The commonest cause of haemorrhage is uterine atony and this should be controlled in
a systematic way according to standard protocols, with oxytocics, uterine massage and
intramuscular injection of prostaglandin F2a (Carboprost) as necessary. Carboprost
should be kept as third-line therapy. A prospective, double-blind, randomized com-
parison of prophylactic intramyometrial 15-methyl prostaglandin F2a and intravenous
oxytocin in cases of elective sections, showed that routine prostaglandins did not oer
any advantage over oxytocin for the control of haemorrhage.
109
When haemorrhage continues, the next step is to check for lateral and vertical
extensions of the incision and trauma to the uterine vessels. Haemostatic sutures to
the placental bed have been recommended and used successfully.
109
Thereafter
unilateral or bilateral ligation of the uterine arteries is recommended.
110
This suture
should also include veins, along with a full thickness of myometrium. O'Leary and co-
workers reported failure with this procedure and a need to resort to hysterectomy in
only 10 cases in a series of 265 patients with uncontrolled haemorrhage.
110a
A wider
knowledge of the procedure of ligation of internal iliac arteries is necessary among
obstetricians, as a lower rate of caesarean hysterectomy has been reported with its
use.
111113
The `B-Lynch Brace' suturing technique involves a single suture enveloping
the body of the uterus, occluding the blood supply temporarily and allowing
stabilization and further assessment of the patient (Figure 9).
114
Blood transfusion
Blood transfusions should not be prescribed without a strong indication, especially as
the majority of the obstetric population in a developed country will compensate for
blood loss without compromise to other systems. However, uid replacement should
be adequate and timely. In patients at risk of losing a large volume within minutes,
blood should be replaced quickly.
115
In a retrospective study over 12 years, which included 1618 women who had a
caesarean section, the transfusion rate was 2.4%.
116
However, Naef and co-workers, in
their retrospective study of 1610 women delivered by caesarean section, found 103 (6%)
to have been transfused. The authors went on to compare the outcome of those who
had been transfused with a matched group of women who had experienced a
haemorrhage but who did not have transfusion. Patients in the transfused group
received an average of nearly 4 units of packed red cells (with a range of 1 to 40 units).
The mean equilibrated post-operative haematocrit was signicantly higher in these
women than in the non-transfused group (28.4+5.4% versus 22.7+4.6%: P 5 0.0001).
Despite this, the hospital stay, post-operative infection and wound complication rates
were similar in the two groups.
117
(a)
Fallopian tube
Round ligament
Broad ligament
1 6
2 5
3 4
4 cm
3 cm
3 cm
3 cm
(b)
Fallopian tube
Ligament of ovary
(c)
Figure 9. The `B-Lynch Brace' suture. (a) Method of B-Lynch suture. (b) Posterior surface of the uterus. (c)
The B-Lynch suture after completion.
Injuries to urinary and gastrointestinal tract
Surgical injuries to the urinary and the gastrointestinal tract during caesarean section
are infrequent. However, their recognition and their proper management are
important in preventing further morbidity.
Bladder injuries
The bladder is at risk of injury in cases of emergency sections, repeat sections, previous
abdominal surgery and obstructed labour. Precautions should be taken to drain the
bladder before surgery. The surgeon should avoid haste and should open the abdomen
in a controlled manner.
118
If necessary, the dissection should be carried out with sharp
instruments and the peritoneum should be opened higher up in cases of dense
adhesions and in obstructed labour. An adequate bladder ap should be mobilized by
sharp dissection in cases of scarring with the lower uterine segment.
The reported incidence of bladder injuries varies from 0.0016 to 0.94%. The
incidence was 0.31% in a 5-year study conducted by Eisenkop and co-workers.
100
In a
series of 11 284 caesarean sections an incidence of 0.14% was reported and 75% of these
injuries occurred at the time of emergency caesarean section.
23
Inadvertent opening of
the bladder at the time of caesarean section should be recognized immediately by the
presence of a Foley's catheter in the operating eld or by drainage of urine. The extent
of the damage should be assessed by noting the location and size of the defect and its
proximity to the trigone and the ureteric orices. The expertise of a urologist needs
to be sought in cases of extensive damage. A simple cystotomy can be closed in two
layers, using absorbable sutures of 2-0 or 3-0 calibre. The mucosa is sutured rst and
the submucosa and the muscularis are included in the second layer. The integrity of
the suturing can be tested with sterile milk or methylene blue dye injected into the
bladder. The serosa should be apposed if feasible. Bladder injuries usually heal very
well, but for this the bladder needs to be drained for a minimum period of 710 days.
A suprapubic catheter, prophylactic antibiotics and cystourethrogram are not thought
to be necessary.
118
Injury to the bladder at the time of caesarean section does not
usually involve the trigone. If any doubt arises, ureteral integrity needs to be checked.
Ureteric catheters may need to be used before suturing the bladder.
Ureteric injuries
These injuries are rare, with the reported incidence ranging from 0.02 to 0.05%.
92,100a
The majority of ureteric injuries that occur are due to attempts to control bleeding
from extension of the angle of the uterine incision into the broad ligament. Although
it is generally believed that the left ureter is more prone to damage because of its
anterior placement (due to the dextro-rotation of the uterus), the studies by Eisenkop
and Rajasekar do not support this.
These injuries are associated with less morbidity when repaired immediately,
avoiding the need for a second operation. Recognition again is dependent upon the
type and site of the injury. Injuries due to clamping, crushing or kinking of the ureter
by a clamp or a suture, not leading to devitalization of the suture, can be reversed by
undoing the procedure. Subsequently, urinary function should be checked and a
peritoneal drain needs to be left. A urologist's opinion should be sought and he/she
may recommend placement of a ureteric catheter via an incision in the bladder.
Severe injuries of transection to the distal ureter can lead to devitalization, due to
devascularization, requiring uretero-neocystotomy. A urologist should be involved
immediately. Some ureteric injuries are diagnosed only post-natally. Following a
dicult caesarean section, with a lateral `pelvic wall' placement of suture to control
haemorrhage, a high index of suspicion should exist. In such cases, a renal ultrasound
should be undertaken prior to discharge or if any symptoms of obstruction develop.
Gastrointestinal injuries
Nielson and Hokegard reported an incidence of 0.08% of bowel injury in a series of
1319 caesarean sections.
119
Bowel is at particular risk of injury in women with previous
abdominal surgery for inammatory bowel disease. Bowel can also be adherent to the
previous scar, or higher on the uterus in cases where myomectomy, closure of
perforation of uterus or previous classical sections have been performed. The bowel is
usually injured at the time of entering the peritoneal cavity, or when dissecting the
bowel from the uterus for gaining access to make an incision, or when an incision
extends on to the adherent bowel.
Bowel injury can be avoided by careful sharp dissection of adherent bowel, avoiding
haste in opening the peritoneal cavity, especially in women who have had previous
abdominal surgery, and by employing a vertical incision. Whenever the uterine
incision is involved in an extension into the broad ligament, loops of bowel should be
kept away while suturing and checking for injury.
Small bowel injury
When an injury to the bowel is suspected or recognized before delivery of the fetus,
the area should be marked with a stitch and covered with a moist abdominal pack. The
site should be inspected for repair after the uterine incision is closed.
118
Management depends on the size, depth and number of injuries and the vascularity
of the involved segment of the bowel. Small serosal injuries can be left alone. Larger
serosal defects should be sutured using 2-0 or 3-0 absorbable or non-absorbable
suture, keeping the suturing line perpendicular to the axis of the bowel. When full-
thickness injuries are encountered, either a single-layer or double-layer closure is
advised. A single-layer closure, using a delayed absorbable monolament, with the
knots within the lumen of the bowel, has been shown to allow greater blood ow,
decreased inammation and greater lumen size compared to a double-layer
closure.
120,121
An end-to-end anastomosis after resection is required when greater
than one-half of the circumference of the bowel is involved, or when blood supply is
compromised or when the injuries are over multiple sites. A general or colorectal
surgeon's help is essential in managing these injuries. Systemic antibiotics are not
usually required. Early feeds with clear uids are recommended.
118
Large bowel injuries
These injuries are managed in the same way as small bowel injuries. Randomized
studies have shown that penetrating injuries of the large bowel can be managed by
primary closure, regardless of the amount of faecal contamination. A colostomy is no
longer considered necessary for patients with large bowel injury. Drains are not
usually necessary, and systemic antibiotics should be started intraoperatively.
118
CONCLUSION
The safety of caesarean section can be improved by adopting proper basic techniques,
combined with evidence based developments covering a number of aspects of care. Joel
Cohen's incision, single-layer closure when feasible, and non-peritonealization are
currently recommended. This is a eld which warrants further research. The CAESAR
study will hopefully answer some questions. Clinicians and patients should be
encouraged to participate in current and future research developments. Caution is
necessary whenever repeat caesarean sections are performed, and there should be early
senior involvement in complex cases. Anticipation, proper planning and preparation are
key steps in achieving good results.
Acknowledgements
The assistance of the North Staordshire Medical Institute librarians, led by Irene Fenton, is
appreciated.
We are also grateful to Claire Rigby, Clinical Governance Support Ocer, for preparing this
manuscript, and to Nicola Leighton and Linda Lucking (supported by West Midlands Clinical
Trials Grant) for assistance with reference management.
Practice points
Caesarean section key points
. prophylactic antibiotics
. Joel Cohen's incision
. deliver the placenta by continuous cord traction
. leave the uterus in for repair
. single-layer closure of the uterus, if feasible
. no reperitonealizing
Research agenda
. the position of the patient whilst performing the caesarean section to check
whether lateral tilt is absolutely essential
. whether preoperative antibiotic irrigation of the vagina is helpful in reducing
the incidence of post-operative endometritis and wound infection
. whether prophylactic antibiotics are necessary for elective caesarean sections
where the baseline infection rates are very low
. whether exteriorization of the uterus after delivery should be practised
. whether routine swabbing of the uterine cavity after placental delivery is
essential
. the best suture material to perform a satisfactory sub-cuticular suture of the
wound
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Techniques For Performing Caesarean Section

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Techniques For Performing Caesarean Section

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Techniques for performing caesarean section

Karumpuzha R. Hema* MBBS, MRCOG

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